A Rare Case of Thrombus Aspiration Device Stuck in the Stent

Abstract

Hardware loss and entrapment during percutaneous coronary intervention is one of the important complications, which an interventionist should anticipate in his practice. Basic knowledge about various extraction methods is essential to bail out in such situations. We describe a 74-year-old male, in whom a used thrombuster device got stuck in struts of an already deployed stent in the right coronary artery. The device could not be retrieved via various percutaneous maneuvers, necessitating an emergency surgical device retrieval and concomitant coronary bypass.

Percutaneous transluminal coronary angioplasty (PTCA) is an integral part of managing acute coronary syndrome and chronic stable angina refractory to optimal medical management. The technical advances in the PTCA procedure have become a double-edged sword facilitating complex procedures albeit with increased complication risk. Device loss and entrapment are rare complications with an incidence of less than 1%. ¹ We describe one such case, where a thrombus aspiration device got stuck in the already deployed stent and the resultant consequences with final bailout by emergency surgical removal and coronary bypass grafting.

Case Description

A 74-year-old hypertensive male smoker had a known history of coronary artery disease with bare metal stenting to the left anterior descending artery (LAD) and distal right coronary artery (RCA), from a different institute, 3 years ago. He presented with acute angina to a peripheral center, diagnosed as ST-elevation inferior wall myocardial infarction and thrombolysed with streptokinase. He was referred to our institute for postinfarct angina. A 12-lead electrocardiogram showed Q waves in inferior leads. Two-dimensional echo showed an ejection fraction of 45%, mild mitral regurgitation, and inferior wall hypokinesia. He was taken up for coronary angiography, which revealed patent LAD stent, 70 to 80% in-stent restenosis (ISR) of the distal RCA stent with thrombotic 80 to 90% lesion of middle RCA. Ballooning to mid-RCA was done, but stenting was deferred because of a high thrombus burden ( Fig. 1A ). The patient was taken up for staged percutaneous coronary intervention after 24 hours of glycoprotein IIb/IIIa inhibitor infusion. With 6F Judkins Right (JR) guiding catheter (Medtronic, USA) via right femoral access, the lesion was crossed with a Sion Blue Wire (Asahi Intech, Japan). The distal stent ISR was dilated with a 2.5-mm balloon and stented with Synergy 3.0 × 20 mm drug-eluting stent (DES) (Boston Scientific, USA) ( Fig. 1B ). The middle RCA lesion was predilated with a 3-mm balloon and stented with Synergy 3.5 × 28 mm DES (Boston Scientific, USA) ( Fig. 1C ). Post stent deployment, there was thrombolysis in myocardial infarction (TIMI) grade 1 flow with thrombus and ST-elevation in inferior leads II, III, and augmented vector foot with bradycardia.

Fig. 1.

( A ) Angiogram showing 70–80% in-stent restenosis (ISR) of distal right coronary artery (RCA) stent with 80–90% thrombotic lesion of mid-RCA. ( B ) Distal RCA stent deployment. ( C ) Stenting of middle RCA. ( D ) Device stuck in-stent (arrow). ( E ) Stent deformation (arrow) upon thrombus aspiration catheter withdrawal. Also seen buddy wire and balloon. ( F ) Second guide with guide extension and balloon, unable to cross the deformed stent.

A temporary pacemaker was inserted, and thrombus aspiration was planned. Due to financial constraints, an ethylene trioxide sterilized used thrombuster II (Kaneka Medix, Japan) was reused. The thrombus aspirator got stuck in the distal RCA stent during pullback due to a kink in the thrombuster tip ( Figs. 1D and 2 ). A second JR guide was taken through left femoral access. Through a second wire, with Guideliner (Teleflex, USA) support, a 2-mm balloon was advanced and an attempt was made to dislodge the stuck thrombuster from the stent, but in vain. Despite multiple attempts, on gentle pulling, the stent got crumpled with the thrombuster tip and stuck in the middle of the RCA ( Fig. 1E and F ). The patient was taken up for emergency coronary artery bypass grafting with the thrombus aspirator and the entire introduction system in situ in the RCA. Intraoperatively, the crumpled stent and stuck aspirator were removed, and reversed saphenous venous graft (RSVG) to posterolateral artery grafting was done. The postoperative course was uneventful. After 6 months, a check angiogram revealed TIMI III flow in native RCA with ISR of the distal stent and patent RSVG to the right posterolateral artery ( Fig. 3 ). The patient is under follow-up for 2 years and is doing well.

Fig. 2.

( A ) Photograph showing the distal end of a normal thrombuster. ( B and C ) Representative image showing the distal end of a normal ( B ) and kinked ( C ) thrombuster tip. ( D – G ) Representative serial images of kinked thrombuster tip getting stuck in stent struts and crumpling the stent on withdrawal.

Fig. 3.

Follow-up angiogram at 6 months showing patent mid-right coronary artery (RCA) stent and in-stent restenosis (ISR) of distal RCA stent ( A ) and patent saphenous vein graft (SVG) to the right posterolateral ( B ).

Discussion

The incidence of mechanical complications during PTCA ranges from 1 to 3% ¹ and includes coronary perforation, abrupt vessel closure, stent deformation, hardware entrapment, and hardware loss. In a study by Hartzler et al, ² 12 incidences of hardware retainment out of 5,400 procedures (0.2%) were reported over 6 years, with guidewire being the most common equipment retained. In another study by Iturbe et al, ³ device loss occurred in 9 cases (0.38%), and device entrapment occurred in 4 cases (0.17%) out of 2,338 procedures. Stents and guidewires are the most common embolized hardware and have considerable data on them, with paucity of data on other hardware loss. We report a case of a used thrombus aspirator getting stuck to the deployed stent and causing deformation of the stent on attempt to remove. The thrombuster was a sterilized one, which had been reused in this case. While reprocessing and reuse of coronary hardware are not common in the west, ⁴ it is used in developing countries because of the cost reduction and limited availability of resources in the cath laboratory armamentarium. It has been considered safe provided the mechanical integrity is intact, and cleaning and sterilization have been done adequately.

Management of device loss/entrapment includes different techniques through either percutaneous or surgical approach. Masterly inactivity leaving the hardware behind is also preferable in select cases. In the Iturbe et al ³ study, device entrapment needed more surgical removal than the percutaneous approach. While there are various case reports on surgical retrieval of the retained hardware, ^{5 6 7} there are only a few case reports on mechanical complications with thrombus aspiration devices. Akgullu et al ⁸ reported a case of a thrombus aspiration catheter trapped in a coronary artery due to rupture of its main shaft and twisting over the wire while attempting to cross a tight lesion to aspirate a distal thrombus, and the whole system was percutaneously removed with pull. Taguchi et al ⁹ reported an inadvertent coronary endarterectomy during aspiration thrombectomy with a thrombus aspiration catheter in a patient with acute coronary syndrome. Oo Myat et al ¹⁰ described a case of broken tip of a thrombus aspiration catheter in the ectatic left circumflex artery of a young patient with Kawasaki disease, and the tip was retrieved percutaneously. Mehta et al ¹¹ reported a case of broken export catheter tip that got stuck in distal LAD during primary angioplasty and retrieved percutaneously. Our case is unique in that the thrombuster got stuck in the deployed stent. We attempted retrieving the stuck thrombus aspiration device with low-pressure balloon dilation and dislodging the device from the stuck stent struts. Still, the balloon could not be crossed beyond the device even with buddy wire, second guide, and guide extension catheter support. Finally, it was successfully removed surgically, and the patient is doing well on follow-up with a normal check angiogram.

Conclusion

Trapping of coronary hardware could be a nightmare in catheterization laboratory. The cardiologist should be aware of the various retrieval techniques, and when necessary surgical removal should be opted promptly to avoid devastating consequences.